Management of Extremity Venous Thrombosis in Neonates and Infants: An Experience From a Resource Challenged Setting

We aimed to evaluate the outcome of different treatment modalities for extremity venous thrombosis (VT) in neonates and infants, highlighting the current debate on their best tool of management. This retrospective study took place over a 9-year period from January 2009 to December 2017. All treated patients were referred to the vascular and pediatric surgery departments from the neonatal intensive care unit. All patients underwent a thorough history-taking as well as general clinical and local examination of the affected limb. Patients were divided into 2 groups: group I included those who underwent a conservative treated with the sole administration of unfractionated heparin (UFH), whereas group II included those who were treated with UFH plus warfarin. Sixty-three patients were included in this study. They were 36 males and 27 females. Their age ranged from 3 to 302 days. Forty-one (65%) patients had VT in the upper limb, whereas the remaining 22 (35%) had lower extremity VT. The success rate of the nonsurgical treatment was accomplished in 81% of patients. The remaining 19% underwent limb severing, due to established gangrene. The Kaplan-Meier survival method revealed a highly significant increase in both mean and median survival times in those groups treated with heparin and warfarin compared to heparin-only group (P < .001). Nonoperative treatment with anticoagulation or observation (ie, wait-and-see policy) alone may be an easily applicable, effective, and a safe modality for management of VT in neonates and infants, especially in developing countries with poor or highly challenged resource settings

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Concurrent radiochemotherapy versus surgery followed by radiotherapy for hypopharyngeal carcinoma: A single-center study

AbstractBackgroundHypopharyngeal cancer is a rare disease representing about 0.5% of all human malignancies and constituting only 3–5% of all head and neck cancer. Concurrent radiochemotherapy has been recommended as a standard of care in patients with locally advanced squamous cell head and neck carcinomas. There were very few reports about these tumors arising from North Africa.ObjecttiveThis work was a retrospective study at the Ain Shams University hospitals comparing induction chemotherapy and concomitant radiochemotherapy to surgery followed by radiotherapy as regards over all survival.MethodsThis study included 49 patients with hypopharyngeal carcinoma, twenty-three (46.93%) were treated surgically. Surgical excision of the tumor was by pharyngo-laryngo-esophagectomy, except for 2 patients treated by conservative surgery. Postoperative radiotherapy was given to all patients. Twenty sex patients (53.07%) were treated by induction chemotherapy and concomitant radiochemotherapy.ResultsThe mean age was 52.6years (range 25–82). In the present study, females (55.1%) dominated males (44.9%).The most commonly involved subsite, in this study, was the postcricoid area (31 patients=63.3%), followed by the pyriform sinus (16 patients=32.6%), while the posterior pharyngael wall was the site of origin in only two patients (4.1%). According to the AJCC-TNM staging system, 40 patients (81.6%) were advanced stages III and IV, while only 9 patients (18.4%) had an early presentation as stages I and II. Cox proportional-hazard regression was used to compare survival in the two study groups. There was no statistically significant difference in the failure function (death) between patients treated with concomitant radiochemotherapy or surgery followed by radiotherapy after adjusting for the age category, tumor grade, T stage and N stage (proportional hazard, 1.114; 95% CI, 0.574 to 2.163; P, 0.751).Of the variables included in the model, only N1 stage was an independent predictor for the hazard of death after adjusting for the treatment group, age category, tumor grade and T stage (proportional hazard, 2.321; 95% CI, 1.073–5.022; P, 0.033). The model had a −2 log likelihood (likelihood ratio statistic, LRS) of 277.316, which was not statistically significant (P, 0.0501) indicating adequate fit of the full model.ConclusionPostcricoid carcinoma comprises the majority of hypopharyngeal tumors in Egypt. Females are more commonly affected by these tumors, especially postcricoid carcinoma. There was no survival difference between the intended therapy for organ preservation and radical surgery groups. Patients who received concurrent radiochemotherapy had a better chance of survival with a preserved larynx compared with patients who underwent surgery